Re-designing health care: transitioning thoracoscopic pleural biopsies from the operating room to the outpatient setting using simulation for training and testing

Introduction Pleuroscopy is a safe and sensitive alternative to video-assisted thoracic surgery for the diagnosis and management of malignant pleural effusion. Pleuroscopy requires fewer resources and can be offered to patients with reduced surgical fitness. A healthcare re-design project was required to establish pleuroscopy in our hospital system. These projects improve the quality and accessibility of care for patients and often result in multiple changes occurring simultaneously within a complex system. The Systems Engineering Initiative for Patient Safety model highlights the system elements that may be impacted when considering system redesign such as the environment, people/roles, tools/technology, tasks and organization. The resulting impact to our processes, patient/staff safety and desired outcomes is not always predictable when changing one or several elements. Methods Simulation is a key method to integrate into redesign projects to ensure the preparedness of staff, systems and processes involved, although it isn’t always utilized. This redesign involved relocating pleuroscopy procedures from the operating room (OR) suites to an outpatient bronchoscopy suite. Short skills-based simulation sessions (i.e. sub-sections of the workflow) were included for learning specific skills, followed by team simulation events as a final implementation step to ensure readiness. Based on this approach, restructuring of process, team roles, the environment, equipment and more was evaluated using simulation to test each system element undergoing change. Results Simulation provided an essential means to evaluate staffing and roles (i.e. expanded scope of practice for respiratory therapists and nurses); the development of cognitive/visual aids and checklists; policy changes; initial staffing modifications, standardization; environmental changes; process changes and more. During the first year since implementation, 25 pleuroscopy procedures have been successfully completed without any safety events reported. Discussion Systems testing and education using simulation was required to ensure an effective implementation and reinforce the many redesigned elements. Simulation was able to proactively test how this procedure could be achieved safely in the new environment. This article serves to demonstrate the utility of simulation for systems testing and staff training for a large system redesign project moving a diagnostic procedure from the OR to an outpatient bronchoscopy suite.